ESPE Yearbook of Paediatric Endocrinology

Lancet Diabetes Endocrinol 2019; 7: 150–60. DOI 10.1016/S2213-8587(18)30074-3

• Access to blood glucose monitoring is often poor in resource-limited settings.

• The authors analyse the reasons for suboptimal access, with a focus on cost, availability, system accuracy, competitive bidding, technological trends, and non-financial barriers. Urine glucose monitoring is an alternative where there are cost considerations.

Emphasis has been placed mostly on insulin access for the management of Type 1 diabetes in children. However, blood glucose monitoring is a key component of diabetes management and is typically very expensive in resource-limited settings. Looking at 15 low- and middle-income countries, these authors found that the median cost of 2 glucose strips was 1.00 USD, which is more than twice the median cost of daily insulin needs, making blood glucose monitoring unaffordable for the most patients.

This was acknowledged in the 2018 edition of the ISPAD Clinical Practice Guidelines, which now includes a section for diabetes management in resource-limited settings. The guidelines state that “glucose monitoring is very expensive. We recognize that in many countries the cost of these assessments relative to the cost of living may make this technology unavailable… All centers caring for young people with diabetes should urge nations, states, and health care providers to ensure that children and adolescents with diabetes have adequate glucose monitoring supplies” (1).

In 2017, the World Health Organization (WHO) released the first edition of the “Model List of Essential In Vitro Diagnostics” (“essential diagnostics list”, EDL), which is intended “to provide evidence-based guidance to countries for creating their own lists of essential in vitro diagnostic tests” (2). Blood glucose (determined by glucometer) was included in this original list to “diagnose and screen for diabetes and intermediate hyperglycaemia, to diagnose hypoglycaemia”. Although the concept of ongoing blood glucose monitoring is not clearly spelled out, this is an important first step that highlights for national health authorities the importance of blood glucose determination by glucometer.

The solutions proposed by the authors are similar to those proposed to improve access to insulin. These include preferential pricing for countries with limited resources, regional pooled procurement programs (whereby a larger quantity of strips are bought at a lower price and distributed between countries), and a World Health Organization (WHO) prequalification scheme, whereby affordable meter and strip systems undergo quality assessment procedures with the aim of increasing market competition and, as a consequence, decrease the price of strips.

References: 1. Codner E, Acerini CL, Craig ME, Hofer SE, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Limited Care Guidance Appendix. Pediatr Diabetes 2018; 19 (Suppl. 27): 328–338.

2. First WHO Model List of Essential In Vitro Diagnostics. Geneva: World Health Organization; 2019 (WHO Technical Report Series, No. 1017). Available at: https://www.who.int/medical_devices/diagnostics/WHO_EDL_2018.pdf (Accessed June 26, 2019).